Pediatric Routine Dental Examination Note

Dentist: Dr. Sarah Jenkins Nurse: Chloe Evans Patient Attended At: 14:30 With: Mother (Mrs. Claire Davies)

Examination

C/O: The patient attended for a routine dental check-up and reports no current pain or sensitivity.

MH: The patient has mild asthma managed with a salbutamol (Ventolin®) 100 mcg inhaler PRN, with no other medical changes confirmed by his mother.

DH:

• Brushing: 2 times per day
• Diet, Sugar: MOD (frequently consumes biscuits and gummy sweets after school)
• Diet, Acid: LOW

E/O: Temporomandibular joints, facial symmetry, lips, and submandibular lymph nodes are all normal with no abnormalities detected.

I/O: Soft tissues are healthy; the patient is in the mixed dentition stage with mild generalized marginal gingivitis and a clinically visible occlusal cavitated lesion on the ULE.

OH: FAIR

Compliance: good

Risk Assessment

Caries Risk: MOD

Perio Risk: LOW

TSL Risk: LOW

Discussed: We discussed the need to reduce the frequency of sugary snacks between meals and the importance of supervised night-time brushing, as well as the options for restoring the decayed ULE.

Treatment Plan

1. Oral hygiene instruction and dietary advice.
2. Topical fluoride varnish application (22,600 ppm NaF).
3. Glass ionomer cement restoration on ULE occlusal.
4. Fissure sealants on all fully erupted first permanent molars (UR6, UL6, LL6, LR6).

Consent: The treatment options, risks, and benefits of restoring the ULE were explained to the mother, Mrs. Claire Davies, who understood and provided signed consent for the treatment plan.

Band: 2

Ortho Assessment: The patient is currently in the early mixed dentition stage with normal molar relationships, so a formal orthodontic assessment is not indicated at this time.

Radiographs

Taken By: Dr. Sarah Jenkins

Left Bitewing

Justification: Caries assessment and investigation of the deep occlusal lesion on ULE.

Report: Grade 1 image quality showing normal alveolar bone levels, with a radiolucency extending into the middle third of the dentine on the occlusal surface of ULE, and no interproximal caries on the left side.

Right Bitewing

Justification: Baseline caries assessment for a moderate-risk patient.

Report: Grade 1 image quality showing normal alveolar bone levels, with all teeth on the right side appearing caries-free and normal eruption of the permanent successors.

Treatment

1. Oral hygiene instruction given to the patient and mother, demonstrating the modified Bass technique and advising to spit instead of rinsing after brushing.
2. Dietary advice provided regarding limiting sugary snacks to mealtimes only and substituting with water or milk between meals.
3. Applied sodium fluoride (Duraphat®) 2.26% varnish to all teeth; post-application instructions were given to avoid eating or drinking for 30 minutes and to eat only soft foods for the rest of the day.

NV: Book 20-minute appointment with Dr. Jenkins in 2 weeks for ULE occlusal GIC restoration and fissure sealants on 6s.

Dr. Sarah Jenkins

General Dental Practitioner